Client type
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Adult (18+)
Minor (aged 0-18)
Client name
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First Name
Last Name
Client Date of Birth
*
Client pronouns
*
Client email address
*
Client phone number
*
(###)
###
####
Guardian's email, enter N/A if 18+
*
Guardian's phone, enter N/A if 18+
*
I'm interested in:
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Select the services you're interested in below; for the best progress, we recommend a team approach—including therapy, nutrition support, and group participation.
Reason for seeking therapy and/or nutritional counseling?
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If you are seeking nutritional counseling and plan to use your insurance, please provide us with a medical or mental health diagnosis, as your insurance may require this information. And let us know of your presenting issue or why you're starting work with us.
General availability ~ mark all that apply
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Will you be using health insurance?
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Yes - BCBS PPO or Choice PPO
Yes - Medicare
Yes - United Healthcare
Yes - Out of network
No - Self pay
Insurance plan name, enter N/A if self pay.
*
Subscriber's first and last name, enter N/A if self pay
*
Subscriber's Date of Birth, enter N/A if self pay
*
Who is the primary subscriber?
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Patient
Patient's spouse
Patient's parent
Other
If other, please explain
Member ID (please include ALL LETTERS & NUMBERS), enter N/A if self pay
*
Group number (please include ALL LETTERS & NUMBERS), enter N/A if self pay
*
Front of Insurance Card, skip if self pay *
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Back of Insurance Card, skip if self pay *
FileField;MaxSize=5120;Multiple;addText=Add_your_Files;
Have you ever been a previous client of Nourishment Works?
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No
Yes
At this time we have limited in-person availability. Please let us know your preference and we will do our best to accommodate your request.
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Virtual Telehealth session
In-person session
Either works for me
